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Full text of "United States Navy Medical News Letter Vol. 34 No. 10, 20 November 1959"

NavMed 369 




UNITED STATES NAVY 



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Rear Admiral Bartholomew W. Hogan MC USN - Surgeon General 
Captain Donald R. Childs MC USN - Editor 



Vol. 34 



Friday, 20 November 1959 



No. 10 



TABLE OF CONTENTS 



ABSTRACTS 



DENTAL SECTION 



Rickettsioses in the U. S 2 

Operability of Mitral Valve Lesions 5 

Irritable Colon Syndrome 7 

Immionity, Infection, and Properdin 10 

Carcinoma and Diverticula of Colon 11 

MISCELLANEOUS 

Research and the Continuing 

Education of the Physician 13 

Vending Machine Evaluation , 15 

Professional Meetings 16 

Military Training Credit - American 

Board of Psychiatry & Neurology. 18 
Directives - 

First-Aid Training Materials 

BuMed Inst. 3500. 1 18 

Residency Training, Application 

BuMed Inst. 1520. lOA 19 

Residency Training, Reporting of 

BuMed Inst. 1520.13 19 

From the Note Book 19 



Effect of Silver Nitrate on Dentin 21 

Training for Leadership 21 

Facings and Backings 23 

Operation of Air Turbines 23 

Continuous Training Program . . 23 

Training for Technicians 24 

Sur g e on of Royal Navy Vi s it s NDS . 2 5 

Reserve Companies Commended . 25 

RESERVE SECTION 

Correspondence Courses 26 

Terminology of Naval Reserve . . 27 

Continuation on Mailing List .... 28 



OCCUPATIONAL MEDICINE 



Low-Back Pain 

Prevention of Low-Back Pain . 
Management of Low -Back Pain. 

Threshold Limit Values 

Radioactive Waste Materials. . , 
Earplugs and Deafening Noises. 



29 
31 
33 
36 
38 
38 



SPECIAL NOTICE 39 



Medical News Letter, Vol. 34, No. 10 



Status of Rickettsioses in the United States 

The major medical problems connected with the rickettsioses affecting 
the hunian inhabitants of the United States have been solved. Nevertheless, 
rickettsial diseases continue to incapacitate nearly 1,000 Americans each 
year, and a number of facts lead toward the conclasion that elimination of 
the reckettsioses of man will not occur in our tinne. 

One of the main reasons for the last statement is the fact that causal 
agents of the four rickettsial diseases currently most important in this 
country — spotted fever, murine typhus, Q fever, and rickettsialpox — are 
maintained in nature in arthropods and animals. Man is not a necessary 
part of their ecologic pattern; he is only accidentally involved in the infection 
cycle, and, when afflicted, does not pass on the organisms to man, arthropods, 
or animals. Man is a dead-end for these rickettsiae. Until these agents are 
eliminated from their arthropod vectors and animal reservoirs, people will 
continue to contract these diseases. 

Spotted Fever . The highest attack rate of spotted fever in the U. S. 
(150 cases per one miDion persons per 5-year period) occurred in Wyoming. 
Three other states in the Rocky Mountain region had rates of Z5 to 50 cases. 
In this area, the wood tick Dermacentor andersoni is the important vector 
of Rickettsia rickettsii , and a number of mammals serve as hosts. In the 
East, where the dog tick, Dermacentor variabilis , is the principal vector, 
and dogs, field nnice, and rabbits serve as hosts, the highest attack rates in 
man occurred in Virginia, with 66 cases per one million persons. However, 
in Maryland, North Carolina, and Georgia, spotted fever was relatively com- 
mon, with 25 to 50 cases occurring in each one million of inhabitants over the 
5-year period. During the sanne time, spotted fever occurred in all but seven 
states, Maine, Vermont, Rhode Island, Connecticut, Michigan, Wisconsin, 
and Minnesota, with the first two states never having reported cases. 

Almost 500 cases of spotted fever occurred annually over the 15-year 
period, 1935 to 1950, with a nnortality rate of 22% throughout most of the 
years. A gradual downward trend of the mortality curve from. 1944 to 1948 
was attributable to the introduction of para-aminobenzoic acid therapy and 
improved supportive m^easures. The impact of highly specific antibiotics on 
mortality rate becanae apparent by 1950. In 1955, mortality from spotted 
fever was about 3%, with a rise to 5.4% in 1956, and 7. 5% in 1957. Along 
with the drop in mortality rate, the morbidity rate has declined — 300 cases 
per year from 1951 to 1956, and 240 in 1957. 

Reduction in the total number of cases of spotted fever in recent years 
cannot be attributed to any recognizable change in the epidemiology or ecology 
of the disease. Widespread use of the broad- spectrum antibiotics may have 
indirectly affected the number of reported cases. Whether the decline in total 
reported cases represents a true fall in incidence or is an artifact, there are 
reasons to anticipate increased incidence of the disease in certain sections of 



Medical News Letter, Vol. 34, No. 10 



the coiontry during the next several decades. Maryland provides an example 
in point through its projected urbanization of the countryside around Baltimore 
and Washington. This region is an endemic area of spotted fever. 

What will be the lines of defense against a probable increase of spotted 
fever in selected areas iindergoing suburbanization? Spotted fever vaccine 
will probably not return to favor because specific antibiotic therapy is now 
available, and large numbers of persons would require immunization in order 
to benefit the few who might become infected. It would seem raore practicable 
to continue the present policy of educating physicians to recognize spotted fever 
in order that they may be alert to the disease and promptly institute adequate 
specific therapy. Use of insect-repellent lotions by persons subject to exposure 
might be employed more widely, thereby reducing insect bites and possible 
disease. 

Murine Typhus . A peak of 5,401 cases of murine typhus occurred in 
1944 with 193 deaths. Subsequently, there was a precipitous drop with the 
current reports indicating about 100 cases a year. Extensive health programs 
dealing with improved sanitary practices, rodent control, and the use of insect- 
icides has played an important part in the rapid decline, although certain natur- 
al factors must be taken into consideration. These factors resulted in a rapid 
fall of the occurrence rate during the years just prior to widespread domestic 
and agricTiltural use of DDT and other insecticides. 

Both murine typhus and bubonic plague are enzootic diseases of commen- 
sal rodents and are transmitted to man by fleas. Plague is famous for its 
pandemics which recur at long intervals, and for the cyclic recurrence of 
epizootics and epidemics at intervals of several decades in endemic areas. The 
murine typhus cycle may result in large part from natural phenomena of the 
general type which are operative in plague. 

The most practical and efficient method for breaking the transmission 
cycle of murine typhus involves control of vector fleas by insecticides. Other 
measures effective in control of the spread of the disease include concern 
with general sanitary measures and procedures which result in decreasing rat 
popiiLations. 

Over the years, the number of deaths from murine typhus has varied 
directly with the total cases, and mortality has remained at about 3.5% despite 
introduction of specific therapy — chloramphenicol or broad spectrum antibiotic s- 
in 1948. 

In the foreseeable future, with use of practical measures which are not 
prohibitive in cost, murine typhus will be eradicated in enlightened urban and 
rural communities. Howeverj in almost all of the endemic areas of the U.S., 
public health and agricultural practices will naerely hold the enzootic disease 
to a relatively low level. 

Q Fever . Q fever differs from other humian rickettsial diseases in its 
route of infection — entry through inhalation of rickettsiae -laden dust or inges- 
tion of infected milk. It is diagnosed most frequently in California, where. 



Medical News Letter, Vol. 34, No. 10 



1952 - 1956, between 60 and 100 hvunan cases were reported annually. In the 
southern part of the State the dairy cow is the main source of infection; in 
the northern part, sheep and goats are the culprits. Serologic surveys show 
that R. burneti is distributed in cattle throughout the western states, and 
recent developments indicate the spread of Q fever into the Middle West. A 
large number of infected cattle have been fotmd in southeastern Wisconsin. 
In this area, alm.ost one -fourth of the human inhabitants gave serologic evi- 
dence of prior Q fever. This infection has also been found in herds of cattle 
in widely scattered counties of Ohio, indicating that Q fever is on the march 
east of the Mississippi, and that normal traffic in cattle will continue to spread 
the disease among domestic animals which in turn will infect man. 

Usable measures for controlling the spread of disease in man include 
adequate pasteurization of all milk, and immunization with vaccines for those 
persons who are appreciably exposed to infected environments. 

Ric ke tt 8 ialp ox ■ This infection was first recognized in New York City 
in 1946. Huebner and Armstrong established the etiologic agent as Rickettsia 
akari , the vector as the mouse mite, and the reservoir as the house mouse. 
About 200 cases are diagnosed annually, mostly in New York City, but a few 
are reported along the Atlantic seaboard from Philadelphia to Boston, and at 
least one case has occurred in Cleveland. 

Miticides, rodenticides, and general sanitary measures could be expect- 
ed to eradicate infection in a given area. It is doubtful that an intense effort 
will be made to eradicate rickettsialpox from a large area. Therefore, about 
the same number of cases will continue to be encountered each year. 

Epidemic Typhus . This disease, the most important menaber of the 
rickettsial group from the worldwide point of view, is of little consequence to 
those living within the United States. In epidemic typhus, man himself serves 
as the only known reservoir of the agent. In the U. S. at this time, it occurs 
only as the recurrent form of the malady, Brill-Zinsser disease, found in areas 
of concentration of body lice. In populations free of body lice, patients with 
recurrent typhus constitute no threat to the community. In this respect, it is 
significeint that the seasonal migration of farm laborers from Mexico increases 
annually, and that these transient residents are now employed throughout the 
West. As long as epidemic typhus exists in the land of our neighbors to the 
South, the itinerant Mexican laborer may supplant the eastern European immi- 
grant as a potential source of Rickettsia prowazeki in the United States. 

It is worth recalling that the current freedom from epidemic typhus and 
infestation with body lice depends as much on the high general standards of 
sanitation as it does on specific control measures, such as lousicides, spe- 
cific vaccines, and specific antibiotic therapy. The capacity to maintain sup- 
plies of each of these deterrents would disappear with the first shower of 
H bombs. The question, then, is not whether epidemic typhus would appear 
among survivors of an atomic holocaust; but, how soon would it appear? 
{Smadel, J. E. , Status of the Rickettsioses in the United States: Ann. Int. Med. , 
51: 421-435, September 1959) 



Medical News Letter, Vol. 34, No. 10 



Criteria for Operability of Mitral Valve Lesions 

Ten years have elapsed since stenosis of the mitral valve was shown to 
be a surgically remediable lesion. Because effective surgery is now the pro- 
vince of a number of clinics, a great deal has been learned about rheuraatic 
heart disease in its varied aspects, and today there should be an unassailable 
hemodynamic formula or formulae for the selection of the patient for operation. 
Unfortunately, there is still no simple answer. 

The most direct approach to the assessnnent of a significantly stenotic 
mitral valve would appear to lie in measurement of the diastolic pressure 
gradient across the valve. Catheterization of the left heart has rendered this 
feasible. However, the gradient is a reflection of at least three variables: 
degree of stenosis, blood flow across the valve, and time during which flow 
passes the valve. 

A considerable body of data has been secured by right heart catheteriza- 
tion, although this information is less direct. Utilizing this technique and 
measuring heart rate, blood flow, and pressure, it has been learned which 
hemodynamic alterations are found in patients with mitral stenosis and which 
variables will be returned toward normal by successful surgery. 

At present, there are six hemodynamic patterns that can be found in 
patients with auscultatory findings of mitral stenosis. The expected and most 
universally accepted picture is that in which at rest there is moderate to severe 
pulmonary hypertension, elevation of pulmonary wedge pressure, and cardiac 
output that is slightly or moderately reduced. These findings occur at heart 
rates from 60 to 100 per minute. The pulmonary artery pulse pressure is 
strikingly increased. The mean pulmonary wedge pressure is quantitatively 
the same as the pulmonary artery diastolic pressure. 

Pulmonary artery systolic and pulse pressures are seen to rise more 
strikingly than diastolic because they are influenced not only by elevation of 
the left atrial pressure, but also by the distensibility characteristics of the 
vessels themselves, the caliber and elasticity of the vessels, the volunne of 
blood in them, and pulsatile flow. In reviewing available data, one is struck 
by the tremendous variation in the level of cardiac output. Attempts at corre- 
lation with pulmonary artery pressures or wedge pressures yield no consistent 
results. Correlations with such calculations as "pulmonary vascular resistance" 
and "mitral orifice size" prove little as the level of blood flow is an integral part 
of these calculations. It is suggested that the integrity of the ventricular pump 
may well play a role. 

The majority of patients who demonstrate this first pattern should have 
a successful result from mitral surgery. The abnormal vascular pressures 
return toward normal, although the cardiac output does not show the same 
striking change. The best explanation for this lies in the fact that existing 
myocardial damage has not been reversed by surgery and that mitral block is 
not the sole regulating factor in determining the level of cardiac output. 



Medical News Letter, Vol. 34, No. 10 



Another hemodynamic pattern that may be encountered is similar to 
the first one except for a much greater magnitude of pulm.onary hypertension. 
Perhaps this is an indication that the linaits of distensibility of the system have 
been reached. The pulmonary wedge pressure does not show such a marked 
change, a consequence of anatomic changes in the walls of the pulmonary 
vascular tree. 

The third group represents mild but significant mitral block. Patients 
often complain of dyspnea, particularly when under more than usual duress. 
Cardiac size is slightly increased and the ECG is within normal limits. 
Studies reveal either norinal pressures or only minor elevations in pulmonary 
artery and wedge pressures at rest. The cardiac output may be normal or 
strikingly reduced. On exercise, blood flow is increased normally, but pul- 
monary artery pressures rise briskly, achieving levels not unlike those en- 
covmtered in the first group at rest. The valve orifice is not as small as 
encountered in the first two groups, but under conditions of stress the stenosis 
becomes important. Surgery in these individuals results in a normal level of 
pressure on exercise. 

The fourth group is hemodynamically not unlike the third at rest. Dis- 
ability is as great as is encountered in those with moderate or severe resting 
hypertension. Repeated bouts of congestive failure are often encountered. 
The heart size is large and atrial fibrillation is often present. On exercise, 
blood flow does not increase nornnally, and pulmonary artery pressures either 
do not rise or do so modestly. Surgery does not change either the clinical 
course or hemodynamic picture. It is likely that myocardial insufficiency is 
the responsible agent for the clinical picture, valvular stenosis not being the 
predominant lesion. 

Patients in the fourth group are most frequently confused clinically with 
those who have tight mitral stenosis because of the degree of their disability, 
but hemodynamically they can be separated. When these patients with myo- 
cardial insxifficiency are in congestive failure, pulmonary hypertension and 
an elevation of right ventricular diastolic pressure develop; they constitute 
the fifth group. Their resting pulmonary hypertension might lead to consider- 
ation of mitral block rather than advanced myocardial insufficiency. The true 
state of this group can be clarified by the finding of an elevated right ventricu- 
lar end-diastolic pressure and by the rigorous use of all medical therapies. 
If such patients are studied following the relief of congestive heart failure, 
marked falls in the lesser circuit pressures will be noted. In the authors' 
experience, surgery has not altered the clinical or hemodynamic picture of 
these patients. 

Patients who display normal cardiodynamics at rest and during exercise 
give no indication for surgery, and constitute the sixth group. 

While successful surgery in mitral stenosis has permitted a definition 
of the hemodynamic consequences of this lesion, mitral regurgitaion has not 
proved an:ienable to operation. There is insecurity in stating which patient 



Medical News Letter, Vol. 34, No. 10 



with mitral insufficiency should be offered surgery. At present, it cannot be 
stated which hemodynamic abnormalities may be ascribed to mitral valve 
insufficiency, which laid to resulting or concomitant ventricular damage, or 
which reflect associated valve lesions. Identification of a significant lesion 
is problematic. Therefore, hemodynamic indications for repair of this lesion 
cannot be stated. {Harvey, R. M, , Ferrer, M.I, , A Consideration of Hemo- 
dynamic Criteria for Operability in Mitral Stenosis and in Mitral Insufficiency: 
Circulation, XX : 442-450, September 1959) 

?fc SJ? ?fe rfc /fe A 

Irritable Colon Syndromie 

A patient who seeks relief from intestinal discomfort believes his sick- 
ness is caused by some organic disease. Such patients are receptive to sug- 
gestion, and descriptions of their discomforts are often extremely convincing 
of organic disease. The physician must pursue an economical and practical, 
yet conclusive, diagnostic routine. The objective of the examination is proof 
of presence or absence of organic disease. 

Organic diseases of the intestine that must be distinguished from func- 
tional disorders include (1) congenital saalformations, (2) infections and 
infestations, (3) allergic state, (4) hormonal disorders, (5) diseases of un- 
known origin, and (6) neoplasms. Careful history and examination point the 
way toward the logical line of investigation^ 

The irritable colon syndrome is a neuromuscular disturbance of the 
intestine, most prominent in the colon and characterized by feelings of pres- 
sure or pain in the abdoiiien, by constipation, and diarrhea. It may occur 
along with, or may alternate with, other motor disturbances, such as duodenal 
irritability simulating duodenal ulcer, biliary dyskinesia, and other less well- 
defined syndromies. Often, it is accompanied by other symptoms and signs of 
a labile vegetative nervous system, such as erythema, dermographia, dryness 
of the skin, cold hands, instability of the cardiovascular system, and in extreme 
instances, low-grade fever. 

Neuronnuscular disturbance in the colon is of diencephalic origin with 
transnxission to the entire intestine by the autonomic nervous system, creat- 
ing a generalized neuromuscular instability. This disorder may arise in 
response to heredity, environment, or psychic tension. Every complaint of 
a patient presents two components — amount of physical disability present, 
and reactions of the nervous "system to this disability, real or spurious. 

An influence of heredity which often is not considered is the transmis- 
sion of psychic traits or simple instinctive tendencies. Each instinctive 
tendency has constituents of knowing, feeling, and striving. When one is born 
he is endowed with potential mental and physical capabilities — a mixture of 
those of his progenitors, A hereditary tendency toward functional intestinal 
disorders no doubt is of significance in some families. 



8 Medical News Letter, Vol. 34, No. 10 



Environinent can be divided into physical environnnent and psychic en- 
vironment. The latter is created to some degree by the individvial and con- 
sists of successes and failures in individual adaptation to the ever changing 
forces of the physical and social aspects of environment. People have done 
much to stabilize the physical factors of their environment, but in doing so 
they have imposed upon themselves an exacting, competitive, and machine - 
like routine of life. They are haunted by the desires and ambitions of their 
families. Such ambitions often create psychic tension and fatigue as well as 
somatic disorders that can produce or simulate organic disease. 

Fear and anxiety are often prominent features in controlling the con- 
duct of many who are ill from psychic tension. They are often related to the 
person's temperament. A state of psychic tension often antedates onset of 
functional digestive symptoms. Such patients often are trapped and find no 
safe way of escape without sustaining more psychic traunna. 

The most constant characteristic of the irritable colon syndrome is the 
presence of discomfort or pain in the abdomen, not definitely associated with 
any phase of digestion or defecation. This pain accompanies exacerbation of 
colonic dysfunction, occurs at irregular intervals, and lacks the periodic 
regularity of duodenal ulcer. Location, intensity, and duration of the pain 
are variable. It may simulate specific pain syndromes to the point that sur- 
gery is performed. 

Constipation frequently is a manifestation of the irritable colon syn- 
drome. However, there are many stable and stoic persons who are consti- 
pated from causes which are not necessarily associated with this syndrome. 

Another common complaint of those experiencing the irritable colon 
syndrome is diarrhea. What constitutes diarrhea for a particular patient 
depends on the bowel habits that he considers to be normal during health. 
Both acute and chronic diarrhea may be caused by psychic influences. The 
history will often separate that due to organic disease from that caused by 
psychic factors. A common cause of diarrhea is self-medication. Many 
drugs used as vehicles and placebos may be the source of ill-defined intes- 
tinal disorders simulating the irritable colon syndrome. 

Carbohydrate foods in excessive quantity nnay cause intestinal distur- 
bances. Excessive amounts of fat in the diet may cause nausea and vomiting 
ov: result in excessive amounts of feces passed at frequent intervals. 

The patient who has symptoms caused by psychic tension often com- 
plains of a sense of indescribable danger and impending illness, irritability, 
insomnia, anorexia, and slowed thinking. Difficulty in breathing, palpitation, 
vertigo, weakness, increased sweating, dysmenorrhea, and headache also 
may occur. 

In patients who have functional disorders of the colon, the general exam- 
ination does not disclose any evidence of loss of body weight unless anorexia, 
sitophobia, functional vomiting, or diarrhea is present. Examination of the 
abdomen gives normal findings except for subjective discomfort. Cold, moist 



Medical News Letter, Vol. 34, No. 10 



hands and feet, dry mouth and lips, variable pulse rate and blood pressure, 
tenseness, and hyperactive tendon reflexes may be observed. 

In the presence of intestinal disorders associated with diarrhea, the 
following examinations should be performed in the order given: (1) study of 
feces for ova and parasites; (2) examination of blood and urine for evidence 
of poisoning by certain chemicals; (3) proctosigmoidoscopy; (4) roentgeno- 
graphic studies of the stonnach, colon, and, occasionally, the small intestine; 
(5) determination of basal metabolic rate if hyperthyroidism is suspected; 
and (6) bacteriologic cultures of the stools as well as determination of fat 
content. 

When organic and functional intestinal disease coexist, evaluation of 
the degree of each is required. In many instances, a period of observation 
and repeated examination is required before organic and functional disorders 
of the intestine can be differentiated. 

Patients suffering from irritable colon syndrome fall into two groups. 
The first comprises those who are intelligent and have a basis for their fear. 
They are temporarily unadjusted and will recover if proper advice is given. 
The second group includes patients whose judgment is fallacious. They 
believe they have an intestinal disorder, and that their complaints and "case" 
are different from any the physician has ever seen. They are miserable, 
arrogant, evasive, and resistant to treatment. 

During treatnnent of the irritable colon syndrome, the physician must 
be thoroughly convinced that the patient's synnptoms are not caused by mani- 
fest or occult disease of the digestive system. Also, the physician nnust be 
aware that psychic tensions of lesser severity can produce pronounced degrees 
of intestinal neuromuscular dysfunction in those who have been weakly fortified 
by heredity against the vicissitudes of life and unpleasant environments. 

In discussions of treatment with the patient, emphasis is focused on the 
causes of discomforts, and suggestions as to how the patient can make adjust- 
ments in order to overcome the causes. An axiom of Bockus cannot be over- 
emphasized: "Those who approach the problenn of the colonic neurosis with a 
sense of serenity and smugness, emphasizing only routine stereotyped methods, 
are doomed to frequent failure. " 

Discussions with the patient from time to time are necessary in order to 
ascertain the relative significance of his anxieties or psychic tensions, and his 
habits of work, rest, eating, drinking, recreation, and sleep. A bland diet is 
tolerated in most instances better than a restricted one, care being taken that 
it is well balanced. Belladonna and phenobarbital may be required for relief 
of abdominal discomfort and simple measures for correcting constipation 
should be employed. More vigorous measures may be employed as indicated. 
Psychiatry and psychotherapy have a definite place in the treatment of some 
patients who have a colonic neurosis. However, good criteria cannot be given 
for the selection of that particular patient, and psychiatric advice maybe required. 
(Wakefield, E.G., Functional Disorders of the Colon - The Irritable Colon 
Syndrome; Postgrad. Med., 26: 365-374. September 1959) 



10 Medical News Letter, Vol. 34, No. 10 



Immunity, Infection, and Properdin 

The word "immune" derives from the Romans who used it to describe 
those persons declared exempt from taxation and other obligations to the state. 
Later, the understanding of the word changed from the concept of "exemption" 
to the connotation, "rendered safe. " In this sense the word is applied to that 
state in which animals are protected or rendered safe from an infectious 
agent either by prior infection or by experience. 

Refractoriness to infection cannot be considered as an all or none occur- 
rence. Infection is the resultant of the interaction of all the various forces 
of both the infectious particle and the involved host. Each of the multitude of 
reactions is subject to biologic variability and to random hazards of chance 
occurrences. 

The first requirement for successful infection is penetration of the host 
integument by the infectious agent. With the rare exception of those few un- 
usvial infections which are introduced directly into tissues or blood by third- 
party vectors, all infecting agents must pass this barrier. Circulating im- 
mune factors play little part in resisting the act of penetration by the infecting 
agent. 

After penetration, "primary lodgment" or "nidation" takes place before 
further invasion occurs. This is the "decisive period" — a matter of minutes 
or hours — during which serologic factors may first have an effect in "natural 
resistance. " Following this stage, direct local extension of the lesion may 
damage some vital structure and it wovild presumably be resisted again by 
local forces. Alternatively, following widespread dissemination, occurring 
through lymphatic or hematogenous seeding, serologic factors would logically 
be expected to have their greatest effect, either by actual destruction of the 
agent or by potentiating removal and sequestration of the agent by tissues 
containing phagocytic cells. Without actual extension, host tissue damage 
may be brought about by endotoxins or exotoxins and released by the invading 
organism. These may be neutralized by serologic factors. The classic reac- 
tion of toxin and antitoxin is perhaps the best and most easily demonstrable 
specific example of the protective role of antibody. 

Careful control of experimental conditions has made it apparent that a 
remarkable number of defense mechanisms exist. Inany one infection perhaps 
only a few of these are called into play. However, all must be considered in 
the evaluation of the over-all response — resistance to infection. 

For many years, the activities of a particular serum protein were 
recognized, and led to the assumption that it should play some role in natural 
resistance to infection. With complement and magnesium, it was known to lyse 
certain bacteria and erythrocytes, inactivate some viruses, and destroy at 
least one protozoan. Properdin was the name given to the protein, being de- 
rived from the Latin pro and perdere , meaning to prepare to destroy. There 
is discussion as to whether properdin is or is not an "antibody. " Available 



Medical News Letter, Vol. 34, No. 10 11 



data at this time suggest that It is probably a distinct protein with multiple 
biologic activities. 

Properdin is antigenic. Accumulated data suggest that it is a single 
substance antigenically and that the bactericidal, erythrolytic, and virus - 
neutralizing activity are identified with the same antigenic material. 

Properdin is found in the sera of almost all normal mammals. Appar- 
ently, it has a variety of activities against infectious agents in vitro. It would 
seem logical that it should have some biologic function in vivo. Such a func- 
tion has yet to be demonstrated. However, this is not an unusual circumstance, 
as it has been difficult to show a protective role for many other serum factors 
in the intact animal. 

Properdin titers in man have been found to vary from the normal range 
in a variety of diseases. The effect of administration of the protein to exper- 
imental animals has also been studied. Under some selected circunnstances, 
there has been an associated increased resistance to infection and irradiation. 

Thus, while data are available indicating increased natural resistance 
following administration of properdin or substances which increase properdin 
levels, evaluation of the data does not allow the interpretation that properdin 
has any influences in itself. However, the fact that it exists in serum, has 
many biologic activities in vitro, and is related to change in resistance in vivo, 
makes it probable that there is some biologic role and that this should be dennon- 
strable in the future by proper techniques, (Wedgewood, R.J. , Immunity, 
Infection, and Properdin: A. M. A. Arch. Int. Med., 104 : 497-505, September 
1959) 

jfc ij^ ric jfe jfe ^ 

Carcinoma and Diverticula of Colon 

The fact that diverticulitis and diverticulosis may mask or mimic car- 
cinoma was first stressed by Moynihan in 1906. Since that time, numerous 
observers have recognized this problem. One observer noted that carcinoma 
and diverticulitis could not be differentiated in 25% of 105 cases. In another 
series, roentgen diagnosis was correct in 57% of 30 patients. 

A certain danger of this simiJ.taneous occurrence of diverticulosis - 
diverticulitis and carcinoma lies in the attitude of physicians, radiologists, 
and surgeons toward this disease. Statements to the effect that diverticulosis 
produces no symptoms and warrants no treatment tend to lull the unsuspecting 
physician into a false sense of security. It behooves every clinician to look 
upon colon diverticula with suspicion, especially those of the sigmoid, because 
the coexistence in that region of carcinoma and diverticulosis is of higher 
incidence than was once thought to be true. 

Furthermore, the percentage of aged people in America is increasing 
rapidly. According to Shackelford, the incidence of diverticulosis in the 



12 Medical News Letter, Vol. 34, No. 10 



general population is 3%, or 5,000,000 persons. The lesion occurs in 5 to 15% 
of all persons over the age of 40, and 66% of all who reach 85 years of age. 
Of persons having diverticulosis, 20% are destined to develop inflammatory 
disease. Of these, 10 to 15% will require operative treatment, of whom 5 to 
10% may be found to have carcinoma eventually associated with the condition— 
10,000 to 15,000 cases. It is these cases of potential carcinoma and diverti- 
culosis -diverticulitis coexisting that deserve attention. This study hopes to 
help by focusing renewed interest on the age-old problem. 

In the authors' study of 355 cases of carcinoma of the colon in a 5-year 
period (1953 - 1957), 75 (21%) were found to have associated diverticulosis, 
35 in close conjunction with the carcinoma. Diverticula occurred in the sig- 
moid in 56 cases (74. 7%). 

In the group with coexisting disease, some change in bowel habits was 
the most prominent symptom (83%), followed by constipation, flatulence, and 
blood in the stools. Weight loss — more in keeping with carcinoma — was sig- 
nificant in 45% of the patients. Left lower quadrant pain and generalized 
abdominal distress were present in slightly less than half of the patients. The 
pain was lower abdominal, cramp-like, and colicky, even simulating appen- 
dicitis except for location on the left side. 

Abdominal tenderness, especially left lower quadrant, was the most 
common objective finding. An abdominal mass was palpable in 15 of 35 cases. 
In only 2 cases had complete obstruction occurred before admission. 

Anemia, secondary to loss of blood, was noted in 37%, while 48% had 
blood in the stool. 

On proctoscopic examination, 20 of 34 patients showed carcinoma. 
Cytologic exannination of snnears was not employed. Barium enema was per- 
formed in all 35 cases of sigmoid carcinoma. In 32 diverticulosis or diverti- 
culitis was noted, but in only 16 could a definite differentiation be nciade be- 
tween carcinoma and the benign conditions. The presence of diverticula 
should not be considered as evidence that carcinoma is absent in any given 
case. 

There is general agreement that the proper treatment for carcinoma of 
the sigmoid colon is left colectomy. Diverticulitis, when uncomplicated, is 
minaged medically. Surgery is advocated when differentiation between car- 
cinoma and diverticulitis cannot be made. The authors are in agreement 
with recent trends in which surgery is being used more frequently in diverti- 
cular disease. Mortality rates have been reduced substantially. 

Prognosis for patients with diverticulitis and carcinoma has been poor. 
Rauch has shown that 15% of patients having previous inflammatory disease 
with carcinomas survived 5 or nnore years after resection. Another group, 
free of prior inflammatory disease, showed a 32% survival for 5 or more years. 
In view of the serious danger of overlooking a carcinoma in cases of diver- 
ticulitis, the authors endorse recent more aggressive attitudes. They consider 
that this will relieve the patient of much morbidity from possible obstruction 



Medical News Letter, Vol. 34, No. 10 13 



which will then require colostomy, resection of the lesion, and closure of the 
colostotny. 

Relative indications for surgical intervention are: (1) persistent mass, 
(2) repeated bleeding, {3) tenesmus, (4) increasing constipation, {5) persistent 
tenderness and evidence of inflammation, (6) poor response to medical therapy, 
and (7) equivocal x-ray diagnosis. 

The operation of choice in 35 cases of carcinoma of the sigmoid with 
associated diverticulosis was resection of the left colon without colostomy. 
Total colectomy was performed in 3 cases for nn.ultiple colonic carcinomas 
with associated diverticulosis. No postoperative mortality occurred in this 
group. 

Any person having diverticulosis and diverticulitis should not be con- 
sidered to have an insignificant "garden-variety" disease of the colon. Such 
patient should be followed persistently with repeated proctoscopic examina- 
tions and barium enema studies, since he may have symptoms of constipation, 
bowel habit change, and abdominal distress indistinguishable from carcinoma. 
An aggressive attitude will undoubtedly save lives in the future in a population 
which is aging and destined to have more and more colonic diseases. 
(Ponka, J. L. , Fox, J.D. , Brush, B. E. , Coexisting Carcinoma and Diver- 
ticula of the Colon - A Review of Three Hundred and Fifty-Five Cases of Car- 
cinoma of the Colon: A. M. A. Arch. Surg., 79: 373-384, September 1959) 

? S r ?fl f ?i t r ^ j?L jflf 

Research and the Continuing Education 
of the Physician 

Education is a continuing process which is dependent on active studying. 
The best of all study results from application of one's energies to elucidation 
of problems to which the answer is not known. This is usually called research. 

There are many ways in which research may be pursued. It is always 
concerned with wondering, pondering, dreaming, and speculating about the 
subject. It always has to do with formulation of problems; it is searching 
that is important — not getting the answer. 

Medical people vary widely in their essential interest in investigation. 
It is a great mistake to think that the habit of inquiring and the genius for 
searching are limited to those who devote their lives to organized research. 
The searching of a busy practitioner is of a different intensity, spread at 
first over a broad area of his practice. Then, scrutiny may lead to observa- 
tions that demand focal study, sometimes with the help of others. 

The practicing physician has many opportunities to engage in useful re- 
search work. It is of first importance that he study in a field that he knows, 
and that his projects be concerned with some aspect of his regular work. 
Active studying stimulates the teacher, clarifies his ideas, and helps him 



14 Medical News Letter, Vol. 34, No. 10 



gain a clearer vision of fundamental principles, making him a better teacher. 
In a similar way, it stimulates the practitioner, sharpens his powers of ob- 
servation, and throws light on his daily problems, making him a better doctor. 
Good habits of thinking, observing, planning, discriminating, and judging are 
engendered and nurtured by persistent searching. These habits of investiga- 
tion come to be used in all that one does — their development requires constant 
application. 

A research hobby outside one's regular work is seldom helpful. Such 
diversion may tend to reduce a practitioner's interest in his patients and 
their disorders. However, if he has great talent for more fundamental re- 
search, it may lead hina into full-time research in the field of his interest 
and aptitude. 

Pursuit of research in practice is not, and should not be, a separate 
connponent of a physician's life. It does not usually begin as a conscious 
effort in one field. It never conies with ease, but only after long effort and 
disciplined thinking. "Clinical research ranges from the making of observa- 
tions which are incidental to, and inseparable from, good practice, to system- 
atic investigations undertaken deliberately and often over long periods with the 
object of answering specific questions, " Its practice may lead to formulation 
of specific questions and prosecution of more systematic research. 

The question is often asked, "How should a practitioner begin his study?" 
It may be answered — to paraphrase Peabody's famous remark about care of 
patients — by saying that the secret of the study of patients lies in studying 
one's patients. To further the study there are certain practices to be followed 
and habits to formed. 

One has to do with keeping of good records. This practice focuses one's 
attention on the more significant observations and provides data for later exam- 
ination and study. 

Another is concerned with the habit of thinking and pondering over inter- 
esting findings, difficult problems, and striking phenomena. This skill is 
developed only with practice until it becomes a habit. 

Such practices lead to consideration of each difficult case as a problem 
which can be solved by data at hand or easily obtained — a practical research 
attitude which, if persisted in, will soon provide a rich background of know- 
ledge. 

Careful preparation of reports in clear appropriate terms is a necessary 
part of the discipline of research. It opens one's conceptions to exacting scru- 
tiny and shows up shortcomings and imperfections of observations and impres- 
sions. Examination of data and formulation of opinions comprise a constructive 
effort from which ideas arise to prepare the ground for making significant new 
observations. 

The most deleterious adverse influence on prosecution of research is 
being too busy to have time to think, too weary and preoccupied to read or 
wonder. Under such circumstances, it is easy to slip into m.echanical 



Medical News Letter, Vol. 34, No, 10 15 

procedures. As Ritchie has said, "It is a standing temptation of mankind to 
put routine, which calls for no thought and little effort, in place of judgment 
which calls for both. " Development of judgment is essential for all good 
studying. 

Almost as bad is to have a false conception of research — to think it can 
be done easily. What is done easily will neither answer important questions 
nor promote one's education. Failure to realize the need for hard disciplined 
thinking and constant scrutiny of one's observations and deductions is almost 
an insurmountable handicap. 

Other retarding influences include the attempt to do so much that little 
can be accomplished because of failure to restrict the focus of one's studies; 
deviation of one's efforts to make use of expensive equipment and recording 
devices in the belief that the use of these instruments is more scientific than 
the direct pursuit of one's problems by simple appropriate methods; and 
desire for the glamour and prestige of research rather than for the interest, 
pleasure, and satisfaction of searching. 

The practitioner has a special vantage ground for certain types of study. 
He can follow the natural course of disease and its modification by all manner 
of influences. He can study the efficacy and dangers of new remedies. Every 
effective naeasure opens new avenues for research. £ach great advance raises 
many more questions than it answers. Any clinical field in which there is 
nearly universal acceptance of current ideas is ripe for critical questioning. 

The great contribution of practitioners as a body cannot be cited in indi- 
vidual instances. The accumulated good sense of a large number of thoughtful 
physicians has a wonderful influence. It dampens the excessive swings of med- 
ical fashion, buffers the overly enthusiastic claims for ill-founded methods, 
acts as ultimate jury in clinical trials, and has a firm, strong, educational 
influence. 

The critical research attitude of honest thinking and penetrating doubt 
on the part of the physician in active practice is a catalyst which speeds up 
the learning process and gives new knowledge at a different but important 
level. It broadens his mind, increases his comprehension, and, by its inher- 
ent discipline, raises the standard of all aspects of his practice and of that of 
his closer associates. (R. F. Farquharson, M. B. , F. R. C.P, (C), Toronto, 
Canada, Value of Participation in Research in Continuing Education of the 
Practicing Doctor: J. A.M. A., 171 : 112-115, September 5, 1959) 

;tc :{: :(c :{c 4c 3}: 

Vending Machine Evaluation Program 

Examinations for certification of compliance under the National Auto- 
matic Merchandising Association Vending Machine Evaluation Program are 
conducted by the Department of Microbiology and Public Health, Michigan 
State University, and the School of Public Health, Indiana University Research 



16 Medical News Letter, Vol. 34, No. 10 



Foundation. Sanitary evaluations are based upon compliance with "The Vending 
of Foods and Beverages - A Sanitation Ordinance and Code - 1957 Recommen- 
dations of Public Health Service. " The current Listing of Letters of Compliance 
awarded to various manufacturers may be obtained from: National Automatic 
Merchandising Association, 7 South Dearborn St, , Chicago 3, 111. 

:$: :ge 4= $ 4= 4f 

Navy Medical Department Participation 
in Professional Meetings 

Occupational Therapy Association 

LCDR Barbara Munroe MSC USN, staff occupational therapist at U. S. 
Naval Hospital, Philadelphia, Pa. , represented the Bureau of Medicine and 
Surgery at the American Occupational Therapy Association's annual conference 
held in Chicago, 111. , 16-23 October 1959. 

American Public Health Association 

LCDR Harry W. LeBleu MSC USN and CWO Ralph T. Goerner, Jr. , USN 
attended the convention of the American Public Health Association at Atlantic 
City, N. J., 19 - 23 October 1959. They monitored a Preventive Medicine 
Division exhibit which introduced the Manual of Naval Preventive Medicine. 
LCDR LeBleu is presently Head of the Environmental Sanitation Section and 
Mr. Goerner is Head of the Safety Section and Assistant in Sanitation Section 
of the Bureau. 

Armed Forces Obstetrical and Gynecological Seminar 

Approximately 150 service Medical officers and civilian physicians 
attended the Sixth Armed Forces Obstetrical and Gynecological Seminar at the 
U.S. Naval Hospital, Portsmouth, Va. , 26 - 28 October 1959. Most of the 
Chiefs of Services of the various naval hospitals and other members of the 
departments attended the meeting, and, with representatives of other services, 
presented papers, participated in panel discussions, or moderated sessions. 
Many distinguished civilian physicians and teachers from various medical cen- 
ters of the east coast contributed to the effectiveness of the meetings by dis- 
cussing presentations and serving as panel members for round-table discus- 
sions. Of particular interest were the reports on extensive statistical analysis 
of ruptured membranes occurring in naval hospitals, acridine orange fluores- 
cent microscopy technique, isotope localization of the placenta, and progress 
in treatment of ovarian and cervical cancer. William T. Ham, Jr. , Chairman, 
Department of Biophysics and Biometry, Medical College of Virginia, an auth- 
ority on radiation hazards, presented a guest lecture, "Irradiation Hazards to 
Fetal Tissue. " 



Medical News Letter, Vol. 34, No. 10 17 



Chairmen of Departments of Surgery 

CAPT J.J. Timmes MC USN, Chief of Surgery, U.S. Naval Hospital, 
St. Albans, N. Y. , represented the Surgeon General at the Conference of 
Chairmen of Departments of Surgery, Brookhaven National Laboratory, Upton, 
N. Y., 26 - 27 October 1959. The conference, sponsored by the Division of 
Biology and Medicine (Atomic Energy Commission) and the Medical Depart- 
mient of Brookhaven National Laboratory, was the fourth in the series, and 
had as its theme, "Nuclear Medicine in Surgical Research and Practice. " 

Military Medico-Dental Symposiunn 

The tenth annual Military Medico-Dental Symposium at the U.S. Naval 
Hospital, Philadelphia, Pa. , was held 28 - 30 October 1959, under the spon- 
sorship of the Commandant, Fourth Naval District. The theme, "Environmen- 
tal Medicine, " was designed to bring together results of the latest research 
and development by outstanding leaders in their fields. 

Association of American Medical Colleges - MEND 

RADM Edward C. Kenney MC USN, Deputy and Assistant Chief of the 
Bureau, attended the annual meeting of the Association of the American 
Medical Colleges in Chicago, 111. , I November 1959, as representative of 
the Surgeon General. He also participated in the raeeting of government 
representatives and educators on Medical Education for National Defense 
(MEND) where he spoke on training opportunities in the Medical Department 
of the U. S. Navy, 

CAPT Bennett F. Avery MC USN, National Coordinator for the MEND 
Program of the United States, and CAPT Malcolm W. Arnold MC USN, Head 
of the Training Branch, Professional Division of the Bureau, also attended 
the meeting, CAPT Arnold participated in a joint meeting of the Federal 
MEND Council and the Committee of the Association of American Medical 
Colleges, presenting the military aspects of the program for which the Navy 
is Executive Agent. CAPT Avery also participated in the meeting of the 
Council -Committee, which cooperates to establish policy for the program. 
Subsequently, CAPT Avery addressed the assembled deans of the nation's 
medical schools to advise them of the progress of the program and of the 
plans for its future. 

Seventy of the nation's 85 undergraduate medical schools are now affil- 
iated with MEND and receive annual grants designed to extend and improve 
teaching of military and disaster medicine. The office of the MEND National 
Coordinator sponsors symposia on subjects related to defense and disaster 
medicine, and arranges for attendance of medical school faculty members. 
Other functions include distribution of professional literature relevant to 
MEND, publication of lists of speakers to address medical school faculties 
and students on related topics, and dissemination of information to medical 
schools on appropriate aspects of the Federal Government's medical activities. 



18 Medical News Letter, Vol. 34, No. 10 



Covmty Medical Societies Civil Defense Conference 

CAPT Reginald R. Ranabo MC USN, Assistant for Personnel Control 
and Planning, Personnel and Professional Division of the Bureau, attended 
the Tenth County Medical Societies Civil Defense Conference in Chicago, 111. , 
7-8 November 1959, as the representative of the Bureau of Medicine and 
Surgery, 

****** 

Change in Military Training Credit for 
American Board of Psychiatry and Neurology 

The Surgeon General has received a letter from the American Board of 
Psychiatry and Neurology, Inc. , which states a change in policy of establish- 
ing credit for training while on active duty in the military services. 

"At the last meeting of the Board, the action regarding training credit 
for military service was rescinded. In order to gain training credit for 
full-time psychiatric work in military service, it would be necessary 
that this be taken in an approved residency training program, and that 
the Educational Director certify that the applicant was actually in res- 
idency training status and not in a service function. This action is retro- 
active to the date of its earliest implementation. " 

^ ije # 3$: :^ :}: 

Directives 

From time to time attention is invited to directives that are of signifi- 
cant general concern. For economy of space, they are described only by 
number, date, subject, and a statement of purpose. Directives may be 
studied in detail from the complete copy which ustially may be obtained at the 
Administrative or Personnel Office. When not available locally, copies of 
BuMed Directives may be obtained from Navy Supply Center, Oakland, Calif. , 
or Norfolk, Va. , or Naval Weapons Plant, Washington, D. C. 

BCJMED INSTRUCTION 3500. 1 16 October 1959 

Subj: Training materials in support of teaching program in first aid and 
self aid, availability of 

This instruction implements SECNAVINST 3500. 1 (Standardization of teaching 
first aid and self aid) with respect to utilization of NAVMED P-5066 (Syllabus 
of Lesson Plans for Teaching First Aid), and available training aids (films, 
moulage sets of war wounds, and practice materials). 



Medical News Letter, Vol. 34, No. 10 19 

BUMED INSTRUCTION 1520. lOA 27 October 1959 

Subj: Residency training of medical officers, application for 

This instruction provides guidelines for the submission of individual applica- 
tions for residency training. BUMED Instruction 1520. 10 is canceled and 
superseded. 

BUMED INSTRUCTION 1520. 13 27 October 1959 

Subj: Residency training of medical officers, reporting of 

This instruction establishes a new procedure for continuing medical officers 
in residency training without annual forjnal request and approval from BUMED, 
and provides for reporting of residents. It applies to all officers reporting for 
residency training during and after fiscal year I960, regardless of the level of 
training. 

;^ ^ :je :^ ^ :{! 

Fron:i the Note Book 

Interns Deferred . Pentagon has sent notifications to 947 hospital interns who 
were selected for deferment from military service while they undergo resi- 
dency training beginning next July. Applications were received from 1, 553 
interns. As anticipated, there were more applicants than vacancies in surgery, 
internal medicine, obstetrics, and pediatrics; but there was not a single request 
for preventive medicine, for which Army, Navy, and Air Force had sought 46 
appointees. There was only one each in occupational medicine and physical 
medicine. (Washington Report on the Medical Sciences, 12 October 1959) 

U.S.N. Medical Research Laboratory . The October A.M. A. Archives of 
Surgery presents an article by CAPT Joseph Vogel MC USN, describing the 
functions of the Medical Research Laboratory at the Submarine Base, New 
London, Conn. 

Hospital Staphylococcal Infections . Three articles form a symposium on the 
problem of hospital acquired staphylococcal infections in the October 1959 
Annals of Surgery. Emphasis is placed on the need for a relentlessly aggres- 
sive attitude in relation to this continuing problem. 

Digoxin in Treatment of Burns . Correlating their observations with those of 
others in relation to shock that accompanies severe thernnal burns, the 
authors of this Research Report conclude that myocardial failure contributes 
to the low cardiac output which results in reduced peripheral circulation. 



20 Medical News Letter, Vol. 34, No. 10 



Studying reactions In dogs, they report that digoxin combined with replace- 
ment ilviids is required to restore blood flow to normal or to prevent its fall. 
This therapy is suggested for use before fluids are available or to augment 
adequate fluid therapy. (Treatment of Severe Thermal Burns with Digoxin 
and Intravenous Fluids, Naval Medical Field Research Laboratory, Camp 
Lejeune, N. C. , NM 61 01 09. 1. H, September 1959) 

Cholecystitis in Moscow . Some of the features of management of acute cho- 
lecystitis, and anesthesia enaployed for gallbladder surgery in Moscow hos- 
pitals are presented in this article by one of the staff of Central Institute for 
Improvement of Physicians. A less conservative viewpoint is presented than 
is usually held by physicians in the U.S. (B. K. Ossipov, Surgery, September 
1959) 

Intravenous Catheter. A newly available disposable sterile needle and cathe- 
ter set offers considerable facility in administration of intravenous fluids over 
a prolonged period of time with minimal discomfort to the patient. Employ- 
ment of the equipment in over 1, 000 cases is described. (H. Gritsch and 
C. Ballinger, J. A.M. A., 19 September 1959) 

Griseofulvin for Tinea Capitis . Faced with an increasing incidence of tinea 
capitis among school children and their preschool siblings, the District of 
Columbia's Department of Public Health have treated, or now have under 
treatment with griseovulvin, 120 children with mycotic scalp infection. 
Eighty-one are apparently cured and no serious side effects or toxic reactions 
have been noted. Treatment must be prolonged until culture confirms eradica- 
tion of the organisms. (J. Kirk, M.D. , L. Ajello, Ph. D. , A. M. A. Arch. 
Dermat. , September 1959) 

Surgery for Arterial Insufficiency . Studies in patients with cerebral arterial 
insufficiency indicating extracranial occlusion in a large percentage of cases, 
and practical application of arterial reconstructive techniques which restore 
circulation represent a departure from the usual concepts of the disease and 
its management. (M.E. De Bakey, et al. ,Ann. Int. Med., September 1959) 

Plastic Conduit in CA of Stomach . Segnnents of a plastic tube molded in the 
shape of the lower esophagus, stomach, and duodenum have been placed as a 
permanent indwelling conduit to provide palliation for patients with obstructing 
gastric carcinonna. (B. Eiseman, et al. , Surg, Gynec. & Obst. , October 1959) 

Toxic Megacolon . This condition is the most dreaded complication of ulcera- 
tive colitis. Therapy must be intensive and comprehensive. Case histories are 
presented detailing some of the problems associated with management of this 
condition. (J. Roth, et al. , Gastroenterology, September 1959) 



Medical News Letter, Vol, 34, No, 10 21 




DEMTAL ft . m . s SECTION 



Effects of Silver Nitrate on Human Dentin and Pulp 

Silver nitrate, anriinoniacal and plain, was applied to the carious dentin 
of Z5 teeth of persons 17 to Z8 years of age. A 5-minute application of ammon- 
iacal silver nitrate followed by reduction with eugenol for 5 minutes was made 
on the carious dentin of 5 nonexposed and 10 carious exposed teeth. These 15 
teeth were sealed with zinc oxide and eugenol cement and extracted 9 to 32 days 
afterward. Silver nitrate was applied to the carious dentin of 10 nonexposed 
teeth for 5 and 10 minutes and was followed by eugenol. These teeth were ex- 
tracted within an hour following application. Upon histologic exannination, it 
was foxind that silver nitrate completely penetrated the carious dentin and par- 
ticles of silver could be found within the pulps of all 5 nonexposed specimens 
extracted 9 to 32 days after application. Silver particles were observed within 
degenerating odontoblasts and other pulpal cells and were deposited around 
capillaries. Silver nitrate had also completely penetrated the vital dentin of 
all carious exposed teeth. In 2 of the 10 teeth extracted within one hour after 
application, there was complete penetration of the dentin by silver nitrate and 
only superficial penetration in the remaining 8 teeth. No differences in pene- 
tration were noted between 5 and 10 -minute applications of silver nitrate, and 
reactions of the dentin to ammoniacal and plain silver nitrate were similar. 
This study confirms a previous report and demonstrates that silver nitrate 
eventually penetrates the entire thickness of dentin and enters the pulp. 
(Englander, H. R. , James, V. E. , Dental Research Facility, Naval Training 
Center, Great Lakes, 111. , Abstract: International Association for Dental 
Research, 35th General Meeting; March 1957) 

* * :^ * * * 

Moral Education and Training for Leadership 

Certainly, the one essential element of combat readiness is effective 
leadership — in the last analysis, based on morally consistent precepts and 
examples. Technical virtuosity keeps equipment in repair and locates the 
right button to push. A transient enthusiasm can move people to explosive 
activity, but leadership based on convictions about the rightness of our social 
order and of our moral institutions, and bolstered by the leader's conduct and 



22 Medical News Letter, Vol. 34, No. 10 



example is needed over the long pull to do the right thing — the right thing 
from the standpoint of efficiency and human relations as well as of moral 
Tightness. 

There is the well known story about the farmer who listened in silence 
to the many recommendations made to him by an expert from an agriculture 
improvement bureau and then led the expert to a bookshelf full of pamphlets 
and publications. The farmer said, "You're absolutely right. Mister, but 
look at all those good ideas ahead of you. I ain't farming now so good as I 
know how. " 

Men look to others to see how to behave, and in particular they look 
to those higher up the totem pole for clues to good behavior — whether it be 
in military situations, social situations, or moral situations. If the top 
man shows an interest in improving leadership and in improving conduct, and 
performance of duty, the men under him will begin to see ways and means of 
educating and training themselves to heightened moral responsibility. 

As Dr. Louis Finkelstein, writing in Fortune Magazine (The Business- 
man's Moral Failure ), September 1958, put it: 

"The businessman can, without moralizing . . . transform his home 
into a school for moral responsibility, . . . The stories he tells, the ges- 
tures he makes, the conversation he chooses and avoids . . . without 
being in the slightest degree priggish, and eventually without self conscious- 
ness, he may help his family and friends obtain insight into the ethical life. 

"The American businessman should literally place ethics on the agenda — 
for himself at home and in the office, for his company and trade associa- 
tion. His calendar should include regular meetings of management to 
discuss the moral dimensions in his specific business. . , . He should 
put moral health on the same level as mental and physical health — indeed, 
above them. " 

If this is a valid observation as regards businessmen, how much more 
so is it valid for a Naval officer who is intimately associated with his men 24 
hours a day in a profession whose issues are life and death, not profit and loss. 

We in the Navy must not forget that we are, in the last analysis, leaders 
of men, and not just of technology in which we place so much confidence and to 
which we devote so much time. 

{The Honorable Richard Jackson, Assistant Secretary of the Navy for Personnel 
and Reserve Forces: Excerpts from article. Naval Training Bulletin, Summer 
1959) 

:i: :^ :^ :ff 4: 4: 



Medical News Letter, Vol. 34, No. 10 23 



Procurement of Facings and Backing s 

The FieldBranchof the Bureau of Medicine and Surgery and the Military- 
Medical Supply Agency recently completed negotiating an open-end contract 
with the Columbus Dental Mfg. Co. for the procurement of porcelain and 
plastic facings and metal backings. A copy of this contract and instructions 
pertaining to its use will be miailed to all authorized Naval Dental prosthetic 
facilities during November, 

jj* »A« 'A' ■»•' jjf Jj 

Air Requirements for Operation of Air Turbines 

Air pressure requirements for the proper operation of air turbine 
handpieces vary according to the manufacturer. However, approximately one 
(1) cubic foot per minute at twenty-five (25) pounds per square inch should be 
available per handpiece. Because many variables, such as age, condition, 
location, and recovery period of compressors determine their efficiency, 
all activities requisitioning air turbine handpieces in accordance with BuMed 
Notice 6750 of 15 July 1959 shall determine that adequate air requirements 
are available to efficiently operate these units and shall include a statement 
to this effect in their justification. 

Air turbine bearings are sensitive and contaminated air lines cause 
rapid destruction of the bearings and markedly interfere with the efficiency 
of the turbine. Compressors and lines must be adequately filtered to elimi- 
nate water and dirt. 

•Jft ^Jm %lr ^L' UU mX^ 

itfi ^^ ryi ^^ ^^ ^p* 

Dental Corps Continuous Training Program 

A short course in Partial Dentures will be presented by the Naval Dental 
School, NNMC, Bethesda, Md. , 11 through 15 January I960. This course is 
intended as a refresher in the basic principles of design of the removable par- 
tial denture. Emphasis will be placed on mouth preparation, making accurate 
impressions, studying survey and design, recording maxillomandibular relation- 
ships, and patient education. The course will consist of lectures, demonstra- 
tions, a seminar, and individual supervision of limited exercises. Instructor 
for the course will be CAPT M. H. Brown DC USN, Diplomate, American Board 
of Prosthodontics, 

Quotas have been assigned to the First, Third, Fourth, Fifth, Sixth, and 
Ninth Naval Districts; and the Potomac River, Severn River, and Naval Air 
Training Commands. 



24 Medical News Letter, Vol. 34, No. 10 



Training for Dental Technicians 

Requests for a course of instruction in Dental Technician, General 
(Basic}, Class "A" School are desired from individuals (strikers or interview- 
ees) in pay grades E-2 and E-3 only , who are not graduates of a class "A" 
School. Minimal prerequisites for assignment are listed in BuMedlnst 1510, 6B. 
Waivers for the combined GCT and ARI score (total of 100 required) may be 
granted up to 15 points depending on other individual qualifications. Classes 
convene every 4 weeks at the Naval Training Center, San Diego, Calif. There 
are 40 training billets in each class; 30 students are allocated directly from 
Recruit Training, and 10 are assigned by the Dental Division upon approval 
of individual request from the field. At the present time, the earliest quota 
available for an eligible striker or interviewee is for the class convening in 
February I960. 

Eligible enlisted personnel are considered for a course of instruction 
in a class convening approxin:iate to rotation tour date or when due for rotation 
in accordance with SEAVEY procedures. 

Training Billets Available to Group XI, Dental Rating. Reference: BuMedlnst 
15I0.2B 

Prosthodontics Basic , 28 billets each class, "C" School, NTC San Diego, 
Calif, , 26 weeks, classes convene February, May, August, and November, 
1960. 

Repair Basic , 5 billets each class, "C" School, NDS NNMC, Bethesda 
Md, , 41 weeks, classes convene September I960. 

Advanced General , 20 billets each class, "B" School, NDS NNMC 
Bethesda, Md, , 26 weeks, classes convene January, July I960. 

Advanced Prosthetic , 10 billets each class, "B" School, NDS NNMC, 
Bethesda, Md. , 26 weeks, classes convene January, July I960. 

Maxillofacial Prosthetics, billets as required. Special Instruction, 
NDS NNMC, Bethesda, Md. , 26 weeks, BtiMedlnst 1510. 4D. 

Medical Administration , 10 billets each class, "C" School, USNH, 
Portsmouth, Va. , 42 weeks, classes convene annually, BuMedlnst 1510. 4D. 

Clinical Laboratory, billets as required, "C" School, Designated USNH, 
52 weeks, BuMedlnst 1510. 4D. 



Please forward requests for change of address for the News Letter to: 
Commanding Officer, U.S. Naval Medical School, National Naval Medical 
Center, Bethesda 14, Md. , giving full name, rank, corps, and old and new 
addresses, 

* * * ii! ^ ;^ 



Medical News Letter, Vol. 34, No. 10 25 



Royal Navy Dental Surgeon Visits Dental Division 

Surgeon Rear Admiral Charles J. Finnigan (D), Royal Navy, Deputy 
Director for Dental Services of Her Majesty's Royal Navy, recently visited 
Rear Adrxiiral C. W. Schantz DC USN, Assistant Chief of the Bureau of 
Medicine and Surgery (Dentistry) and Chief, Dental Division, and members 
of his staff. While Rear Admiral Finnigan was in the United States, he 
attended the Centennial Session of the ADA in New York City, and toured 
various Navy Dental facilities, including the U.S. Naval Dental School, 
NNMC, Bethesda, Md. In a short talk at the Naval Dental School, Rear 
Admiral Finnigan commended the Navy Dental Corps for its worldwide con- 
tribution to dentistry and expressed appreciation for the fine relationship 
which exists between the Royal Navy Dental Corps and the U. S. Navy Dental 
Corps. 

:j( :}: ;jc 3<c :^ !j( 

Reserve Dental Companies Commended 

RADM H. T. Deutermann USN, Commander, USNR Training Command, 
Omaha, Neb. , recently commended the following commanding officers of 
Naval Reserve Dental Companies as having the outstanding Dental Company in 
their respective naval districts: 

CAPT D. H. Nichols DC USNR-R, Company 4-6, Chagrin Falls, Ohio 

CAPT W. H. DeWolf DC USNR, Company 9-6, Evanston, 111. 

CDR R. L. Foutz DC USNR-R, Company U-4, North Hollywood, Calif. 



Policy 

The U.S. Navy Medical News Letter, is basically an official Medical 
Department publication inviting the attention of officers of the Medical 
Department of the Regular Navy and Naval Reserve to timely up-to-date 
items of official and professional interest relative to medicine, dentistry, 
and allied sciences. The amount of information used is only that necessary 
to inform adequately officers of the Medical Department of the existence 
and source of such information. The items used are neither intended to be, 
nor are they, susceptible to use by any officer as a substitute for any item 
or article in its original form. All readers of the News Letter are urged 
to obtain the original of those items of particular interest to the individual. 



^rfi. 



-;s# 



26 Medical News Letter, Vol. 34, No. 10 




RESERVE ^^p^ SECTION 



Correspondence Courses 
Manvial of the Medical Department - Parts I and II 

Manual of the Medical Departnaent, Parti, NavPers 10708-2 (Rev. 1959}f 
and Part II, NavPers 10709-2 (Rev. 1959), are t\wo correspondence courses 
recommended for all Medical Department personnel. They are designed to 
provide familiarity with functions of administration, organization, and man- 
agement of facilities exercised by the Bureau of Medicine and Surgery. Com- 
pletion of these courses will enable the enroUee to acquire essential knowledge 
of significant functions of the Medical Department in its relation to the Naval 
Establishment ashore or afloat in all of its far-flung activities, and to increase 
the enrollee's over -all efficiency. 

Because of the extent of the material, the course has been divided into 
two parts. Each part is administered and credited as a complete course in 
itself. The courses are described here together because they deal with dif- 
ferent parts of the same subject. 

MANUAL OF THE MEDICAL DEPARTMENT - PART I, In addition to 
delineation of authoritative methods and procedures, the material embraces 
discussions of approved essential organizational structure of all types of 
Medical Department components. These include the Bureau of Medicine and 
Surgery, various field agencies in all areas of activities, regional and district 
medical staffs, and Medical Department organization in ships and on shore 
stations. 

Because the Medical Department is guided in matters of administration 
by Navy Regulations, current directives of the Bureau of Medicine and Surgery, 
and the Manual of the Medical Department, certain chapters of the Manual have 
been selected as the principal text for the course. The text constitutes chapters 
1 through 14, 17, 18, 20, 21, and 22, It incorporates page changes 1 through 6 
and is a minor revision of the previous course. SecNav Instructions 6320. Sand 
6320. 9 relating to the Medical Service — Dependents' Medical Care, and Comp- 
troller Fiscal Policies — Dependents' Medical Care and BuPers Instruction 
1750. 5A as reflected in BuPers Notice 1750 of 8 May 1957, are furnished as 
supplementary reading material. However, questions are not based upon this 
material. 

The course consists of nine objective type assignments and is evaluated 
at twenty-four Naval Reserve promotion and/or nondisability retirement points 



Medical News Letter, Vol. 34, No. 10 27 



Naval Reserve personnel who previously completed course NavPers 10708-1 
will not receive additional credit for completing the revised course, NavPers 
10708-2. 

MANUAL OF THE MEDICAL DEPARTMENT - PART IL The course 
provides Medical Department personnel with authoritative standards, methods, 
and procedures as they apply chiefly to three areas: property and fiscal man- 
agement, forms and reports used on various occasions, and the maintenance 
of proper records; and proper application of standards for the physical exam- 
ination of Navy personnel. Material relating to treaties and conventions which 
is of special significance for personnel of the Medical Department is also in- 
cluded. 

The text constitutes chapters 15, 16, 23, 25, 26, and Appendix A. Page 
changes 1 through 6 have been incorporated in this material, reflecting changes 
in foregoing chapters. Additional material is taken from Arnny Regulations 
40-503 (new 1956), Physical Standards and Physical Profiling for Enlistment 
and Induction. 

The course consists of eight objective type assignments and is evaluated 
at eighteen Naval Reserve promotion and/or nondisability retirement points. 
Naval Reserve personnel who previously completed course NavPers 10 709-1 
will not receive additional credit for completing the revised course, NavPers 
10709-2. 

Applications should be submitted via applicant's command, to the 
Commanding Officer, U.S. Naval Medical School, National Naval Medical 
Center, Bethesda 14, Md. , (Attn: Correspondence Training Division). Medical 
personnel may be enrolled in more than one Medical Department correspondence 
course at one time. 

****** 
Terminology of the Naval Reserve 
Terminology commonly used throughout the Naval Reserve: 

ACTIVE DUTY - full-time duty with active military service of the United 
States other than active duty for training. 

ACTIVE DUTY FOR TRAINING - full-time duty with active military service of 
the United States for training purposes, most contimonly the two-week cruise. 

INACTIVE DUTY TRAINING - any training, instruction, or duty as prescribed 
by the Secretary of the Navy, performed by Reservists on inactive duty, with 
or without compensation, is inactive duty training. For example, drills and 
approved correspondence courses are part of this type of training. 

TEMPORARY ACTIVE DUTY - temporary assignment to full-time active duty 
for the purpose of performing a special task. 



28 Medical News Letter, Vol. 34, No. 10 



TEAM TRAINING - intended to provide Reservists with training in general 
knowledge and skills required for all Navymen on active duty. It is not 
intended to be limited to general drill or battle problem exercises, but 
to teach seamanship, damage control, first aid, and the like. 

ALLOWANCE - the number of personnel by grade and designator or rating 
authorized to be assigned to pay units of the Naval Reserve in drill pay 
billets. 

ATTACHED - any Reservist who is assigned to a billet within an authorized 
unit allowance is "attached" to that unit. 

ASSOCIATE QUOTA - the number of billets authorized for a unit in addition 
to its allowance, for training, administrative or procurement support 
purposes. 

ASSOCIATED - any Reservist who is assigned to a billet within an authorized 
unit associate quota is "associated" with that unit. 

APPROPRIATE DUTY - this duty is assigned by naval district commandants 
to accomplish various special tasks in connection with the Naval Reserve. 

ORGANIZED NAVAL RESERVE - comprised of all units included in the approved 
Table of Organization, both pay and nonpay, which follows the approved cur- 
riculum of a supervised training program. 

STATUS OF RESERVISTS - every Reservist is in an active, inactive, or retired 
status. 

ACTIVE STATUS - the status of all Ready Reservists and those Standby Reser- 
vists who are not on the Inactive Status List. Such Reservists are identified 
USNR-R, USNR-EV, or USNR-SI. 

INACTIVE STATUS - the status of members of the Standby Reserve who are 
officially placed on the Inactive Status List in accordance with regulations 
prescribed by the Secretary of the Navy. Such Reservists are identified as 
USNR-S2. 

RETIRED STATUS - the status of all members of the Naval Reserve placed on 
the Retired Reserve List in accordance with regulations prescribed by the 
Secretary of the Navy, which includes mennbers on the Honorary Retired 
List as well as those in Retired Pay Status. Such Reservists are identified 
as USNR-Ret. (To be continued) 

*?>■ "V "IN Sr* ^ ^ 

Continuation on Mailing List 

Particular attention of all Reservists — not on active duty — is directed 
to the requirement for returning the notice for continuation on mailing list of 
the Medical News Letter. In many instances, this requirement is overlooked, 
resulting in interruption of receipt of the News Letter. Please return the 
notice appearing on pages 39 and 40 of this issue if the News Letter is desired, 
making sure the form is filled in completely and legibly. 

:^ :$ :^ ^ :^ :^ 



Medical News Letter, Vol. 34, No. 10 29 




OCCUPATIONAL MEDICINE 



Low -Back Pain 

Chronic low-back pain is caused primarily by incompetent ligaments 
and tendons which do not maintain normal tensile strength. This relaxation 
causes joint instability and is frequently confused with disc disability and 
arthritis. 

Pain has its origin when weakened ligament and tendon fibers stretch 
under nornnal tension and permit an abnormal tension- stimulation of somatic 
sensory nerves that will not stretch. 

The diagnosis is made by trigger point tenderness over specific articu- 
lar ligaments. The diagnosis is invariably confirmed by intraligamentous 
tendonous needling with a local anesthetic solution which reproduces the local 
pain and sometinnes specific referred pain, only to disappear within two min- 
utes as anesthesia takes place. 

Ligaments . The inter spinous ligament is the most important ligament 
of the spine because it maintains stability while limiting the range of motion 
of one vertebra upon another. It must be weakened to permit abnormal strain 
of the spinous articular liganaents, abnormal compression of an intervertebral 
disc, or the so-called slipped, crushed, or ruptured disc syndrome. 

When one vertebra normally glides forward on the articular processes 
of the adjoining vertebra below, both the interspinous and supraspinous liga- 
ments assume a more diagnonal position without stretching, as the spines of 
the two vertebrae come slightly closer together. To permit any abnormal 
forward movement of one vertebra on another, such as occurs in spondylo- 
listhesis and compression of an intervertebral disc, fibers of the interspinous 
ligament nnust be torn or stretched, as in chronic relaxation. At the same 
time, the supraspinous ligament may assume a more diagonal position in 
tnoderate cases, but must also be disabled, together with spinous articular 
ligannents and others, in severe cases. Intraspinous relaxation is frequently 
accompanied by relaxation of the articular ligaments on one or both sides of 
the same vertebra. The iliolumbar ligament also is relaxed in lumbosacral 
joint instability, and the sacro-iliac, sacrospinous, and sacrotuberous liga- 
ments are relaxed in instability of the sacro-iliac joint. 

Tendons . A frequent source of lumbar and gluteal pain is weakness of 
the tendonous attachments of the sacrospinalis muscle to the spine and 



30 Medical News Letter, Vol, 34, No. 10 



transverse processes of the lumbar vertebrae and dorsum of the sacrum. 
Weakness of the tendonous attachments of the gluteal muscles to the dorsum 
of the ilium is another common occurrence. Both conditions have been desig- 
nated erroneously as fibrolipomatous nodules, fibrositis, and herniated fat 

pads. 

Referred Pain - Sciatica . Referred pain into the lower extremities 
extending to the toes, and sciatica from incompetency of the lumbosacral 
and sacro-iliac articular ligaments occurs more frequently than from all 
other sources combined. 

During 19 years of observation of 18,000 intraligamentous injections 
made while diagnosing and treating 1,706 patients, definite pain areas re- 
ferred from specific ligaments were charted. These have proved to be 
valuable diagnostic aids because they direct attention to specific disabled 
ligaments. 

Sciatica results when the lower portion of the posterior sacro-iliac, 
sacrospinous, and sacrotuberous ligannents become excessively incompetent 
to maintain stability of the sacro-iliac joint. It is accompanied by sciatic 
nerve tenderness and conducted pain extending to the toes which is distin- 
guishable from the definite areas of referred pain from articular ligaments. 

Treatment. Relaxation or incompetency of ligaments and tendons is 
treated by prolotherapy (rehabilitation of an incompetent structure by induced 
proliferation of new cells), Prolotherapy is accomplished by intraligamen- 
tous injection of a proliferating solution combined with a local anesthetic solu- 
tion. This stimulates the production of new bone and fibrous tissue cells which 
strengthens the "weld" of fibrous tissue to bone and permanently eliminates 
pain and disability. Except for severe cases, treatments can be carried out in 
the office. 

Comment and Statistics . Incompetency of ligaments and tendons follows 
strains and tearing of fibers when normal tensile strength is not regained. 
Treatment involves tendons and articular ligaments from the occiput to the 
feet. Growth of new tissue takes place over a period of about 6 weeks. Fol- 
lowing treatment, the patient is usually able to pursue his ordinary activities. 

Ages of patients treated during this study ranged from 15 to 88 years. 
Duration of disability was 3 months to 65 years. Re -evaluation was inade two 
months after treatment and revealed no unfavorable sequelae. Of 1, 706 
patients treated over a period of 19 years, 8Z% considered themselves per- 
manently cured. (Hackett, G. S. , Low -Back Pain; Indust. Med., 28^: 4l6-419j 
September 1959) 

****** 

Use of funds fof printing this publication has been approved by the 
Director of the Bureau of the Budget (19 June 1958). 

'■'' afC Hi 5n '*''' SJk 



Medical News Letter, Vol. 34, No. 10 



31 



Prevention of Low -Back Pain 

Critical study of approximately 3, 500 cases of low-back pain followed 
over a 20-year period revealed the prinicpal unanswered question: How many 
cases of low-back pain or injuries could have been prevented by selective 
employment or activity? The aim was to establish a yardstick for preemploy- 
ment or job placennent where, by history and examination, it could be ascer- 
tained that a person is predisposed to low-back injury or strain. 

Review of the studies might give some idea of the problems and, in 
turn, help in their solution. Tabulation of preemployment examinations of the 
low back extended over a 7 -year period and involved some 8, 500 cases. 

Critical preemployment examinations, both general and low-back, were 
carried out in two plants where both men and women were employed at jobs 
requiring moderate to heavy lifting. Examinations in both plants covered a 
thorough history with emphasis on previous back pain and/or injuries, and 
included a complete physical examination in addition to special examination 
of the eyes, ears, and back. X-Ray films of the chest and two planes of the 
low back were made. When questionable findings in the lumbosacral region 
were observed, oblique projections were nnade from the right and left sides. 

These examinations were approached more as a preplacement examina- 
tion than as an elimination of the weak or infirm, because these plants freely 
hire handicapped persons, provided they meet the qualifications for the job. 
Restrictions are prescribed as to the nature and conditions of an employee's 
duties as inposed by physical, mental, or emotional limitations he possesses. 



Data revealed by the study: 
Cases examined . . . 8488 

Male employees 8 7% 

Female em.ployees , . . 13% 



Age range in years ... 17-53 
Average age in years .... 31 



X-Ray findings of the first 6, 523 cases were: 

Congenital anonftalies in the lumbosacral region ..... 41. 1% 

NormLal spines 39. 93% 

Wear-and tear changes in lumbosacral joint 6, 3% 

Postural curvature 5. 0% 

Advanced spinal arthritis 3. 3% 

Structural scoliosis 1. 9% 

Increased lumbar lordosis 1. 3% 

Old compression fracture 0. 7% 

Opaque material in neural canal 0. 47% 

Overlapping spinal structural abnormalities and/or pathology made 
accurate classification difficult. Grouping into various categories was based 
on the most outstanding x-ray finding. 



32 Medical News Letter, Vol. 34, No. 10 



Under congenital defects, the following are listed in the order of their 
occurrence: 

Malformed lumbosacral articulating facets 

Spina bifida occulta of the first sacral segment 

Supernum^erary lumbar vertebrae 

Sacralized last lumbar vertebra 

Cleft or failure of fusion of the last lumbar vertebra 

Spondylolisthesis 

Four lumbar vertebrae 

Many cases show wear and tear changes of the lumbosacral joint, where 
there is a settling of the lumbosacral space with resulting arthritic changes. 
These cases were found to be most susceptible to developing pain in the low 
back, even from minor or no injury. 

Comparison is made with statistics of the x-ray studies of preemployment 
examinations and the reported series of 3, 500 patients who sought relief in the 
clinic for low-back pain and/or disability. 

Preemployment Examinations Low- Back Disability 

Percentage Series, Percentage 

Congenital 

anomalie s 41.1 31,1 

Arthritis 3.3 15.1 

Negative x-ray 

findings 39.9 13.8 

Postural defects 5.0 13.3 

Wear-and-tear 

changes in lumbo- 
sacral joint 6.3 2.3 

All other s 4.4 24.4 

On the basis of these examinations, employment was refused to 3. 8% 
of all applicants and 12. 7% were assigned to limited or specific duty — duty 
which the examiner believed could be handled by the applicant without the 
risk of causing injury to the lower back. 

Over the period of study, with increased efficiency of preemployment 
examinations and past experience, the number of applicants rejected for 
employment increased and the number of low-back cases reporting to sick 
call decreased. 

X-Ray findings of lumbosacral region in order of importance: 
1. Congenital anomalies 
Spondyloli s the sis 
Cleft or failure of fusion of last lumbar vertebra 



Medical News Letter, Vol. 34, No. 10 33 



Congenital anomalies (continued) 
Sacralized last lumbar vertebra 

2. Arthritis 

3. Postural defects 

4. Wear-and-tear changes in the lumbar spine and/or lumbosacral joint 

A program of preemployment examinations of the low-back or lumbo- 
sacral area will help identify employment hazards and serve as a basis for 
job placement. It might be more accurate to term these preplacement rather 
than preemployment examinations. (Diveley, R. L. , Low-Back Pain - Pre- 
vention through Medical Examination and Selective Job Placement: A. M. A. 
Arch. Indust. Health, 19: 572-5 76, June 1959) 

'n T* "T^ T* T" 1* 

Conservative Management of Low-Back Pain 

Intelligent management of low-back pain by conservative means depends 
upon accurate diagnosis of the cause of the pain, removal of the cause when 
possible, and evaluation and treatment of factors which cause the pain, even 
though they may not be completely correctible. 

Accurate diagnosis of low-back pain is one of the most difficult and 
complex problems in the field of medicine. Because of its complexity there 
has been a tendency to group all cases together in ill-defined categories — 
"disc, " "low-back strain, " or "sacro-iliac. " 

There have been successive waves of popular diagnosis which have little 
or no specific meaning, such as "lumbago" (any back pain and stiffness in the 
back), "sciatica" {any pain radiating down the posterior region of the thigh), 
and "sacro-iliac strain" (pain in the back with radiation of pain into the post- 
erior region of one thigh). The idea of protruded intervertebral disc has 
become so popular that almost any back pain has been called a "disc pain. " 
The tendency is to consider most back pains as the result of disc trouble. 

Treatment 

Particularly in back pain, certain factors indicate physical treatment 
which is presented from the point of view of the modalities used, including 
diathernny, massage, and traction. 

Physical therapy is not machine therapy. It should be prescribed for a 
definite pathologic or physiolgic condition which can reasonably be expected 
to be improved by physical therapy and should not be continued when no benefit 
is produced. 

Acute Pain . Probably the most important factor in relief of pain which 
usually accompanies muscle spasm during the acute stage, is bedrest with 



34 Medical News Letter, Vol. 34, No. 10 

1 

a firm mattress and a bedboard which covers the entire surface of the 
spring. A sponge -rubber mattress is satisfactory only when used on a 
'Isedboard. 

Williams' position of flexion at hips and knees with flexion of the trunk 
gives relief of pain in many patients, particularly those who have spasm 
in the iliopsoas muscles. The Williams' brace also is useftil in some 
patients during subacute and chronic stages. Support of the trunk is bene - 
ficial in certain acute cases. Taping or a firm belt may be quite useful in 
relieving pain for those who can be up and around. 

Traction in bed is a time-honored treatment; however, it seems that the 
mild degree of traction which is ordinarily tolerated for a long period is of 
little benefit. Bedrest is probably more useful than traction. Heavy trac- 
tion of short duration, in sitting or supine position, may be employed. 

Hot packs are of great value in treating pain. Packs of a very high 
temperature with low water content should be applied frequently, depending 
on severity of pain. In severe cases packs are applied once every 10 to 15 
minutes and continued as long as necessary to relieve pain. 

Aspirin and codeine are the stand-by medications; however, sedatives 
are necessary in the acute stages in order to give the patient relief from 
severe pain. 

Muscle Spasm . This usually accompanies pain, and most of the proced- 
ures which are used for pain are also useful for relief of muscle spasm. 
In addition, guarded passive and active motion within the limits of pain, 
or just reaching to the limits of pain, is valixable. 

Postural exercises in bed in the acute stage are often useful, particular- 
ly back flattening and abdominal exercises, provided they do not cause pain. 
In addition to sedatives, tranquilizers are sometimes helpful. Muscle 
relaxants are not particularly satisfactory. 

When the subacute stage has been reached, massage is added for relaxa- 
tion of muscle spasm. Massage must be of a sedative type without violent 
naovements which would increase muscle spasm. It is best given by an 
experienced therapist rather than by a member of the patient's family. 
Active exercise is then gradually increased. Infrared heat treatment may 
be used in place of hot packs. Diathermy may be used instead of hot packs, 
especially if hypertrophic arthritis is present. 

Muscle Contracture (subacute and chronic stages) . Muscle contractures 
are important causes for prolonged disability. Many patients with low-back 
pain are in a flexed position in bed for a long time. This promotes hip- 
flexion contractures. The ilopsoas is often involved in muscle spasm; in 
fact, it is probably the most common reason for sciatic scoliosis. The 
erector spinae muscles are commonly involved and almost regularly show 
shortening which limits forward flexion. These contractures may be pres- 
ent even after an operation has been performed and the disc renaoved. Many 
of these patients get imnaediate and complete relief from sciatic pain, but 



Medical News Letter, Vol. 34, No. 10 35 



they often continue to exhibit back pain which is more commonly related 
to the contractures in the back than to hyper mobility. The gastrocnemius 
and soleus muscles also are not infrequently involved in contractures. 

Treatment is begun by use of heat. The type of heat used depends upon 
the type of equipnnent available, the time the patient has for treatment, and 
many other factors. Moist heat is preferable to dry heat and may be given 
in the form, of hot packs, whirlpool, or Hubbard tank. Infrared, diathermy, 
and uitrasotind are not of significant use in overcoming contractures. After 
the tissues have been softened by the use of heat, stretching is employed. 
Manual stretch is useful in many instances, but is not as efficient as a pro- 
longed stretch. Prolonged stretch is usually given by first stabilizing the 
part and then applying weights over a long period — half hour, hour, and 
sometimes more. The most effective method is to devise a technique by 
which the patient himself can stretch the part. This allows more prolonged 
treatment because it can be given at home rather than in the physical therapy 
department. 

Muscle Weakness. If muscle weakness is the result of interruption of 
the nerve by pressure from a protruded disc or tumor, proper treatnnent is 
removal of the pressure by surgery as early as possible. However, many 
of these patients become weak because they must be in bed or, at least, are 
not carrying out normal activity over fairly long periods. During the acute 
stage, strengthening exercises may be used to all nonpainful areas in order 
to prevent deconditioning. The patient should be kept in norntial physical 
condition throughout convalescence so that the recovery period may be 
shortened and he may return to work at the earliest possible moment. Even 
a short stay in bed without exercise may produce an astonishing degree of 
weakness. 

During the subacute and chronic stages, strengthening exercises may be 
used for any weak muscles, starting with postural exercises and stressing 
back flattening. However, this obviously depends upon the factors that are 
causing disability. Progressive resistance exercises are undoubtedly the 
best method for producing hypertrophy of muscles and, thereby, producing 
increased strength. Bracing is to be avoided when possible. Braces tend 
to promote weakness and interfere with methods of developing strength, 
and they often give the patient so much psychologic support that it is very 
difficult to get him to discard them when they are no longer needed. Often, 
patients have to be readmitted to the hospital in order to get rid of a brace. 

Manipulation . Manipulation is performed for relief of lumbosacral pain, 
supposedly and probably, by opening the intervertebral space enough to allow 
a disc to recede. Good results have been obtained in about one -third of the 
patients. This manipulation is most useful in the patient who has a sudden 
onset of acute back pain after a bending, twisting motion. It is not the result 
of straining to lift a heavy object — usually he doesn't get to lift the object he 
was reaching for. 



36 Medical News Letter, Vol. 34, No. 10 



In the facet syndrome or subluxation of the sacro-iliac joint manipula- 
tion, the patient is laid on his side and a rotary motion of the pelvis is 
produced. Some effective results are reported. 

C onclusion 

In carrying out conservative management of cases of back pain, the 
first and most important requirement is establishment of an accurate diag- 
nosis—not only of the cause of the disease or injury, but also of the factors 
that are influencing the case at the time of examination, either prolonging 
the disability or making the patient incapable of returning to work. If these 
factors are evaluated and treated rationally, progress can be acconnplished. 
Most patients can be treated conservatively; however, this does not mean 
using a routine back treatment or ordering a physical therapist to "give physio- 
therapy to the back. " Treatment must be prescribed specifically by the phys- 
ician to correct the pathologic conditions found on examination. Treatm.ent 
must be changed as these conditions change. If the treatment is not effective, 
it should be changed or discontinued. When relief can be obtained and adequate 
instruction given to the patient as to how he should carry out his activities, or 
if his type of work is changed to avoid what causes his disability, he may be 
able to continue for long periods without further trouble. 

Back pain is a difficult problem to solve by conservative treatnnent, but 
if approached analytically, much can be accomplished. (Knapp, M. E. , 
Low-Back Pain - Conservative Management: Arch. Indust. Health, 19: 577- 
584. June 1959} 

4: :{: ^ # :!i ^ 

Changes in Threshold Limit Values 

Threshold limit values contained in BuMed Instruction 6260. 5, Change 2, of 
19 December 1957, were taken frona values adopted at the 19th Annual Meeting 
of the American Conference of Governmental Industrial Hygienists in April 
1957. Changes adopted by the 20th Annual Meeting were noted in the Medical 
News Letter, Vol. 32, No. 6, dated 19 September 1958. Changes as listed 
in the table were adopted by the 21st Annual Meeting in April 1959, and pub- 
lished in the Archives of Industrial Health, September 1959. Changes adopt- 
ed in 1958 have been included to bring BuMed Instruction 6260. 5 up to date. 

"Threshold limits should be used as guides in the control of health 
hazards and should not be regarded as fine lines between safe and danger- 
ous concentrations. They represent conditions under which it is believed 
that nearly all workers may be repeatedly exposed, day after day, without 
adverse effect. The values listed refer to time weighted average concentra- 
tions for a normal work-day. The amount by which these figures may be 



Medical News Letter, Vol. 34, No. 10 



37 



exceeded for short periods without injury to health depends upon a number 
of factors, such as the nature of the contaminant, whether very high con- 
centrations even for short periods produce acute poisoning, whether the 
effects are cumulative, the frequency with which high concentrations occur. 

Table 



Change values listed under "Established Values" as folloTsfs: 



PPM 



Approx. Mg. per Cu. M. 



Bromine 


0.1 


0.7 


Chloroform (trichloromethane) 


50 


240 


Chloroplcrin 


0.1 


0.7 


Nitric acid 


10 


25 


Mesltyl oxide 


25 


100 



Add to "Established Values" list the following: 
Gases and Vapors 



PPM 



Approx. M^. per Cu. ^ M. 



Acetylene tetrabromlde 

Acrylonitrile 

a-Methyl styrene 

^k>no^lethyl aniline 

Paradichlorobenzene 

Propylene oxide 

Tertiary butyl alcohol 

Tolylene-2,4-diisocyanate 

Trie thy 1 amine 

Vinyl toluene 

Xylidine 

Toxic Dusts. Fumes, and Mists 

Beryllium 

Add to "Tentative Threshold Limit Values" the following: 



1 


14 


20 


—45- 


100 


480 


2 


9 


75 


450 


100 


240 


100 


300 


0.1 


0.7 


25 


100 


100 


480 


5 


25 




Micrograms per Cu. M, 




2 



PPM Approx. Mg. per Cu. M. 



Chlorine dioxide 


0.1 


0.3 


1,1 -Dimethyl hydrazine 


0.5 


1 


sec-Hexyl acetate 


100 


590 


Phosphoric acid 




1 


n-Propyl nitrate 


25 


110 


1,2, 3-Trichloropropane 


50 


300 


Triorthocresyl phosphate 




0.1 



38 Medical News Letter, Vol. 34, No. 10 



and the duration of such periods. All must be taken into consideration 
in arriving at a decision as to whether a hazardous situation exists. Special 
consideration should be given to the application of these values in the eval- 
uation of the health hazards which nxay be associated with exposure to com- 
binations of two or more substances, 

"Threshold limits are based on the best available information from indus- 
trial experience, from experimental studies, and, when possible, from a 
combination of the two. These values are based on various criteria of toxic 
effects or on marked discomfort; thus, they should not be used as a common 
denominator of toxicity, nor should they be considered as the sole criterion 
in proving or disproving diagnosis of suspceted occupational diseases. 

"These limits are intended for use in the field of industrial hygiene and 
should be employed by persons trained in this field. They are not intended 
for use, or for modification for use, in the evaluation or control of com- 
munity air pollution or air-pollution nuisances. 

"These values are reviewed annually by the Committee on Threshold 
Limits for changes, revisions, or additions as further information becomes 
available. The Committee welcomes the suggestion of substances to be added 
to the list and also comments, references, or reports of experiences with 
these materials. " 

J^ S^ «^ ^f¥ ^fi ^^ 

fiadioactive Waste Materials 

By 1980, industry will have to find safe ways to segregate 100 million 
gallons of waste naaterials having a high radioactivity equal to 100 billion curies. 
Dr. Abel Wolman of the Johns Hopkins University testified before the Joint 
Congressional Committee on Atomic Energy. Dr. Wolman said that rapid devel- 
opment of the atomic energy industry is in no small measure contingent on find- 
ing safe and econontiical methods of waste disposition. (Signs and Symptoms of 
Trends in Public Health: Pub. Health Rep, , 74: 594, July 1959) 

Earplugs Shut Out Deafening Noises 

Connfortable earplugs to shut out deafening noises are recommended by 
Dr. Aram Glorig, Head, American Academy of the Ophthalmology and Otolaryn- 
gology's research center on noise in industry. He finds that workers who wear 
earplugs have normal hearing at the end of a working day. Those who do not 
wear plugs lose hearing, particularly at 4000 cycles. 

Some workers object to wearing earplugs, fearing that warning cries of 
danger would go unheard. Glorig says that the opposite is true. Loud noises 
are shut out by the plugs and speech is made more intelligible. (Signs and 
Symptoms of Trends in Public Health: Pub. Health Rep. , 74: 594, July 1959) 



Medical News Letter, Vol. 34, No. 10 39 

SPECIAL NOTICE 

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{Continued on page 40) 



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Medical News Letter, Vol. 34, No. 10 



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